States Are Moving on Health Care Reform : In the absence of a national plan, some states are tackling comprehensive coverage of the uninsured.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy.

“For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government.”

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse.

Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation, but that should not be interpreted as a code word for social Darwinism, or survival of the healthiest, wealthiest, and luckiest, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures, not only for the lessons they hold, but also for the encouragement they provide, experts said.

“A lot of people feel if California as a state can make meaningful inroads in terms of our coverage and cost challenges, then that offers some hope and promise for other states, just given the size and the magnitude of our challenges,” Ms. Belshe said.